STATE OF FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES IN THE MATTER OF Certified Mail 7009 3410 0001 6527 9031 A Civil Penalty Against Return Receipt Requested Tadpoles & Toads, Inc. d/b/a Tadpoles & Toad Childcare Learning Center 6902 Lillian Road Jacksonville, Florida 32211 ADMINISTRATIVE COMPLAINT YOU ARE HEREBY NOTIFIED that the Department has imposed a Civil Penalty in the amount of Sixty Dollars ($ 60.00), against Tadpoles & Toads, Inc. d/b/a Tadpoles & Toad Childcare Learning Center. As grounds for the imposition of this penalty, the Department states the following: 1. The State of Florida, Department of Children and Families (DCF) has jurisdiction over this matter by virtue of the provisions of Sections 402.301 — 402.319, Florida Statutes. 2. The Respondent, Tadpoles & Toads, Inc., is licensed to operate Tadpoles & Toads Childcare Learning Center -License # C04DU0456, located at 6902 Lillian Road, Jacksonville, Florida,32211as a Child Care Facility in compliance with Chapter 402, Florida Statutes (F.S.), and Florida Administrative Code (F.A.C), Rule 65C-22. Violation 3. During an inspection on March 25, 2011, a DCF Licensing Counselor determined that: Documentation of a DH Form 680 Florida Certification of Immunization was missing for a child (Z.E.). 4. FAC Rule 65C-22.006 (2) (c), states, the childcare facility is responsible for obtaining for each child in care, a current, complete, and properly executed Florida Certification of Immunization Form Part A-1, B, or C, DH 680 (July 2001), or Religious Exemption Immunization Form, DH 681 (May 1999), which are incorporated herein by reference, from the custodial parent or legal guardian. DH Form 680 and DH Form 681 may be obtained from the local county health department. Immunizations received out of state are acceptable, however, Filed May 2, 2011 2:16 PM Division of Administrative Hearings immunizations must be documented on the Florida Certification of Immunization Form and must be signed by a physician practicing in the State of Florida. If the custodial parents or legal guardians fail to provide the documentation required in paragraph (a) or (c) above within 30 days of enrollment, the facility shall not allow the child to remain in the program. Pursuant to the Florida Administrative Code Rule 65C-22.006 (2) (c), this is a Class 3 violation. This same Class 3 violation was previously cited on April 15, 2009, July 28, 2010 and November 17, 2010. Pursuant to the Child Care Facility Standards Classification Summary, CF-FSP Form 5316, Item #57-Children’s immunization, the fine for this fourth Class 3 violation is $30.00. Violation-l 5. During an inspection on March 25, 2011, a DCF Licensing Counselor determined that: Documentation of DH 3040 (June 2002) Student Health Examination Form was missing for child (Z.E.) 6. FAC Rule 65C-22.006 (2) (a), states, the childcare facility is responsible for obtaining for each child in care a current, complete and properly executed Student Health Examination Form DH 3040 (June 2002) from the parent or legal guardian or a statement by authorized professionals that indicates the result of the components of the Student Health Examination form are included in the health examination. The Student Health shall be completed by a person given authority to perform health examinations. The Student Health Examination or the signed statement is valid for two (2) years from the date the physical was performed. An up-to-date version must be on file for as long as the child is enrolled at the facility. The childcare facility is also responsible for obtaining for each child in care a current , complete and properly executed Florida Certification of Immunization Form Part A-1, B, or C, DH 680 (July 2001), or Religious Exemption Immunization Form, DH 681 (May 1999), which are incorporated herein by reference, from the custodial parent or legal guardian. if the custodial parents or legal guardians fail to provide this documentation within 30 days of enrollment, the facility shall not allow the child to remain in the program. Pursuant to the Florida Administrative Code Rule 65C-22.006 (2) (a), this is a Class 3 violation. This same Class 3 violation was previously cited on August 5, 2009, July 28, 2010 and November 17, 2010. Pursuant to the Child Care Facility Standards Classification Summary, CF-FSP Form 5316, Item # 57- Children’s immunization, the fine for this fourth Class 3 violation is $30.00. 7. The above referenced violation constitutes grounds to levy this Civil Penalty pursuant to ss.402.310(1)(a) and 402.310(4), Florida Statutes as the above referenced conduct of Respondent constitutes a violation of the minimum standards, rules and regulations for the operation of a Child Care Facility. 8. Payment of money order or cashier’s check for this fine can be made directly to the Department of Children and Family Services. The mailing address is: 5920 Arlington Expressway, P.O. Box 2417, Jacksonville, FL. 32231, Attention: Child Care Licensure. 9. Failure to pay the fine imposed in this Administrative Complaint will result in an automatic non-renewal of the license referenced above. NOTICE OF RIGHTS NOTIFICATION OF RIGHTS UNDER CHAPTER 120, FLORIDA STATUTES IF YOU BELIEVE THE DEPARTMENT'S DECISION IS IN ERROR, YOU MAY REQUEST AN ADMINISTRATIVE HEARING TO CONTEST THE DECISION. YOUR REQUEST FOR AN ADMINISTRATIVE HEARING MUST BE RECEIVED BY THE DEPARTMENT WITHIN 21 CALENDAR DAYS OF YOUR RECEIPT OF THIS NOTICE. FAILURE TO REQUEST AN ADMINISTRATIVE HEARING WITHIN THE 21 DAYS PROVIDED SHALL CONSTITUTE A WAIVER OF THE RIGHT TO A HEARING. You may submit your request for an administrative hearing to the Department at the following addresses: David Tucker Gregory D. Venz, Agency Clerk Chief Legal Counsel Department of Children & Families Department of Children & Families Office of the General Counsel P.O. Box 2417 1323 Winewood Blvd., Bldg. 1, Suite 407 Jacksonville, FL. 32231-0083 Tallahassee, FL. 32301 Please note that a request for an administrative hearing must comply with section 120.569(2) (c), Florida Statutes, and Rules 28-106.201(2), Florida Administrative Code. Those provisions, when read together, require a petition for administrative hearing to include: (a) The name and address of each agency affected and each agency's file or identification number, if known; (b) The name, address, and telephone number of the petitioner; the name, address, and telephone number of the petitioner's representative, if any, which shall be the address for service purposes during the course of the proceeding; and an explanation of how the petitioner's substantial interests will be affected by the agency determination; (c) A statement of when and how the petitioner received notice of the agency decision; (d) A statement of all disputed issues of material facts. If there are none, the petition must so indicate; (e) A concise statement of the ultimate facts alleged, including the specific facts the petitioner contends warrant reversal or modification of the agency's proposed action; (f) A statement of the specific rules or statutes the petitioner contends require reversal or modification of the agency’s proposed action; and (g) A statement of the relief sought by the petitioner, stating precisely the action petitioner wishes the agency to take with respect to the agency's proposed action. Section 120.569, Florida Statutes, and rule 28-106.201(4), Florida Administrative Code, require that a petition to be dismissed if it is not in substantial compliance with the requirements above. Pursuant to section 120.573, Florida Statutes, the Department advises that formal mediation is not available for this administrative complaint. However, the Department may consider proposals to resolve the complaint without a formal hearing. STATE OF FLORIDA, DEPARTMENT-OF CHILDREN AND FAMILIES Pamela Buckham l Safety Program Manager CERTIFICATION OF SERVICE | HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, 7009 3410 0001 6527 9031, Return Receipt Requested, in accordance with ss. 120.60(3), Florida Statutes (2005), this adMeay of April, 2011. STATE OF FLORIDA, él mer T OF CHILDREN & FAMILIES Pamela Buckham Safety Program Mdnager H Complete Items 1, 2, and 3. Also complete o.ltem 4 if Restricted Delivery is desired. rint-your name and address on the reverse ‘so that we can return the card to you. Attach this card to the back of the mpijpigc on the front if space permits. : Article Addressed to: Des dativerysa Eas: feria pee Ai a ives a Peps s. Tadpofes & Toads Inc. d/b/a DREN R. & ‘ ’s. Tadpoles & Toads Childcare Leaming. — gf WILOREN & FAMILIE 6902 Lillian Road APG Jacksonville, Florida 32211 , . Service Type (Cl Certified Mall [1 Express Mail insured Mall [1 6.0.D. 4. Restricted Delivery? (Extra Fee) 2. Article Numb . ; _ Mansierfrom serviceia__?O0 3410 COOL b527 3031 ' PS Form 3811, February 2004 Domestic Return Recelpt 1 Registered 1 Return Receipt for Merchandise 102595-02-M-1540 ;

Docket for Case No: 11-002215